Provider Demographics
NPI:1245291251
Name:WILSON, JODI ANDERSON (NP)
Entity type:Individual
Prefix:MS
First Name:JODI
Middle Name:ANDERSON
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:JODI
Other - Middle Name:ANDERSON
Other - Last Name:REALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:59 PAGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03570-3531
Mailing Address - Country:US
Mailing Address - Phone:603-788-5764
Mailing Address - Fax:603-326-5831
Practice Address - Street 1:173 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NH
Practice Address - Zip Code:03584-3508
Practice Address - Country:US
Practice Address - Phone:603-788-4911
Practice Address - Fax:603-326-5831
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA180210363L00000X
MARN180210363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110016488AMedicaid
MATX7744Medicare PIN
MAS23351Medicare UPIN